A Menu of Change

Assessing and Promoting the Progress of First Stage Labor

Failure to progress is the primary cause of nearly half (47.1%) of all intrapartum cesarean deliveries.1 Despite widespread use of interventions to speed labor progress, including use of oxytocin and artificial rupture of membranes, the diagnosis of disorders of labor progress appears to account for a large proportion of the increase in cesarean rates over time2 and the variation in cesarean rates across geographic regions.3,4

Obstetric practice has been based on standards of labor progress that have proven to be too stringent and lead to unnecessary cesarean birth.5 Emerging evidence suggests the following changes to traditional standards that were based on Friedman criteria from the 1960s:

expecting longer mean times for cervical dilation,

anticipating slower labor progress in the earlier part of active labor (5-7cm),

observing greater variability in the progress of labor among women, and

awaiting the active phase of labor before diagnosing disorders of labor progress.7-10

Active management of labor, which includes routine amniotomy and treatment of slow labor progress with intravenous oxytocin, represents the prevailing approach to managing labor progress in the United States. The complete active management process includes prenatal education, strict criteria for diagnosing active labor, continuous one-to-one care in labor, use of a partograph to track labor progress, strict criteria for diagnosing disorders of labor progress, and peer review of assisted deliveries. Active management reduces the length of active labor but has had inconsistent effect on cesarean deliveries.11 Although researchers examining active management of labor have not found statistically significant differences in maternal or neonatal morbidity when active management is used, caution is warranted. Oxytocin is a high alert medication that requires continuous monitoring and one-to-one staffing to manage the potential for error or adverse effects. It is the drug most commonly associated with preventable adverse events during childbirth, and allegations of its misuse are the sources of approximately half of all paid obstetric claims.12 On the other hand, physiologic approaches appear to be more reliably effective for promoting spontaneous vaginal birth, have no or minimal risks, and are associated with other benefits, including increased comfort and maternal satisfaction.